Change Process

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In order to assist clients with change, social workers must have a clear understanding of the elements of the transtheoretical change process. Many factors influence how and when change may occur in clients. It is important for social workers to recognize and acknowledge when the client is in a particular phase of change. Doing so provides key opportunities for social workers to support client self-efficacy and address ambivalent feelings the client may have about the change process. Social workers should take care to use professional skills to develop motivational questions and responses to encourage clients through the change process.

For thisAssignment, review the case study, “The School Brawler,”

(see attachment)

and consider the transtheoretical stage of change of the client in the case study. Think about where the client is at the beginning and at the end of the therapy session. Consider interactions in the therapy session that influence the client’s move from one stage to another.

(See attachment for some information on Transtheoretical, plus use your own research on Transtheoretical using only valid resources)


The assignment (2–3 pages)

:

  • Describe the transtheoretical stage of change the client in the case study was in at the beginning of therapy session, and explain why.
  • Describe the transtheoretical stage of change the client is in at the end of the therapy session, and explain why.
  • Describe two interactions that occur in the therapeutic session, and explain how each influences the client’s move from one stage to another.

    Must be in APA format and no plagiarism. Use only resources that are not more than 7 years old

Change Process
Principles of Motivational Interviewing Geared to Stages of Change: A Pedagogical Challenge Katherine van Wormer ABSTRACT.This article discusses the significance of motivational in- terviewing as a framework with wide application across the spectrum of social work practice. This article discusses the basic assumptions of the motivational approach and argues that social workers can regard this as a bridge between treatment agencies organized around competing philos- ophies. Suggestions are made for incorporating content across diverse curriculum areas. doi:10.1300/J067v27n01_02[Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail ad- dress: Website: com> © 2007 by The Haworth Press, Inc. All rights reserved.] KEYWORDS.Motivational interviewing, harm reduction, addiction, substance abuse, stages of change INTRODUCTION Social work educators strive to present class content that parallels the treatment needs of agencies while at the same time preparing students to assume leadership positions regarding the introduction of treatment in- novations, especially of those that are evidence based. One area that is often overlooked, perhaps because ofits affiliation with substance abuse Katherine van Wormer, MSSW, PhD, is Professor of Social Work, University of Northern Iowa, 36 Sabin Hall, Cedar Falls, IA 50614 (E-mail: [email protected]). Journal of Teaching in Social Work, Vol. 27(1/2) 2007 Available online at http://jtsw.haworthpress.com © 2007 by The Haworth Press, Inc. All rights reserved. doi:10.1300/J067v27n01_0221 counseling, is the change-inducing strategy generally known as motiva – tional interviewing (MI). An Internet search (as of November, 2004) of “Social Work Abstracts” revealed a mere 11 listings for articles on the subject of MI and 14 on the related subject of harm reduction, compared with 278 listings for MI and 507 for harm reduction onPsycInfo. Evi – dently psychologists have given this treatment modality which is aimed at enhancing client motivation much more emphasis than have social workers. And yet, as most readers of this paper will realize, social work – ers have long practiced many of the precepts that now are incorporated in the MI formulation. In any case, because of its wide applicability of such an approach, especially in situations of short-term treatment for clients in situations that are self-destructive (for example, drug misuse, exposure to family violence), MI is of special relevance to the social work profession. This article makes the case that interventions directed toward client lev- els of motivation are highly consistent with social work’s predominant strengths perspective formulation (see Rapp, 1998; Saleebey, 2002). Sug- gestions are made for incorporating motivational content into courses across the social work curriculum including human behavior in the so- cial environment (HBSE), generalist practice, correctional treatment and counseling. WHAT IS MOTIVATIONAL INTERVIEWING? MI is a non-confrontational model based on the fundamental truth from social psychology that decisions to move toward change are more powerful if they come from within. MI is defined by Miller and Rollnick (2002) as “a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (p. 25). This approach is client-centered in the sense that most of the state- ments concerning the toll the drinking, gambling and so on are taking is elicited from the client. There is also a focus, however, on the client’s cognitions to help him or her move in the direction of health-seeking be- haviors (Substance Abuse and Mental Health Services Administration, [SAMHSA]1999, TIP 35). MI is the pragmatic approach most closely associated with the harm reduction or public policy model. The focus is on providing empathic counseling and reinforcing the client’s sense of self efficacy or ability to exert some control over his or her life. From this treatment modality, the therapist assesses the level of the client’s motivation for change. Careful 22 JOURNAL OF TEACHING IN SOCIAL WORK to avoid fighting with the client, the motivational worker rolls with the resistance and in so doing, hopes to dispel it. Motivational techniques are geared to help people find their own path to change; feedback is of – fered to the client about what he or she seems to be saying about the need to reduce or eliminate self-destructive behaviors. MI has been a favored treatment modality in substance abuse treat – ment; it also has wide applicability to any area of social work that is cen – tered on the need for behavioral change. The development of MI is credited to the persistent questioning by young Norwegian psycholo – gists and interns of psychologist William Miller as he demonstrated his techniques for enhancing clients’ receptiveness to substance abuse treat – ment and promote their willingness to change (Miller, 1996). Miller’s protégés wanted to know how this was done and what the theory behind it was. The result was a beginning conceptual model that was followed by years of testing and refinements which culminated in the writing of the groundbreaking text, “Motivational Interviewing: Preparing People to Change Addictive Behavior” (Miller & Rollnick, 1991). My first encounter with the principles of motivational work came through an exchange between my university and social work faculty at a large urban university in northeast Britain. “Of what importance is motivation?” I asked myself at the time, my experience having been solely with involuntary clients. “Who comes to treatment voluntarily, anyway?” I wondered. That’s just the point, of course. When treatment methods (total abstinence, urinalysis tests, confrontational presentation of assessment re- sults) are designed to tear down resistance rather than establish rapport, few people sign up for the experience of their own accord. The expense of U.S. mental health care is an additional inhibiting factor. In the United Kingdom, nationalized health care (The National Health Service) and the availability of neighborhood drop-in clinics are conducive to harm reduction strategies–meeting the client where the client is and helping the clients modify their harmful practices at their own pace. Although the contrasts between European pragmatism and U.S. pu- nitiveness persist, especially regarding chemical dependency, many of the aspects of an individually tailored approach to helping are beginning to gain acceptance (Mueser, Noordsky et al., 2003). For social workprac- titioners, this development can only enhance their success in fields such as correctional and addictions work. In its basic formulation and precepts, MI closely parallels the strengths perspective of social work practice (van Wormer and Davis, 2003). The strengths approach, as Saleebey (2002) suggests, is “a versatile practice approach, relying heavily on ingenuity and creativity, the courage and Katherine van Wormer 23 common sense of both clients and their social workers. It is a collaborative process” (p. 1). According to this positive, feedback-oriented framework which builds on clients’ strengths and resources, client resistance and denial are often viewed as healthy, intelligent responses to a situation that might involve unwelcome court mandates and other intrusive prac – tices (Rapp, 1998). As in the strengths formulation, the focuses of MI is on collaboration of counselor and client, as well as on personal choice (see Saleebey, 2002). When the focus on the professional relationship is on promoting healthy lifestyles and on reducing the problems that the client defines as impor – tant rather than on the substance use per se, many clients can be reached who would otherwise stay away (Denning, 2000; Graham, Brett, & Baron, 1994). Central to this approach is the building of a relationship between therapist and client. In working with youth, this relationship is crucial in terms of promoting self-esteem and the confidence to try on new roles. In the MI orientation, the strategy is to help develop and support the client’s belief that he or she can change; this is the principle of self-efficacy men- tioned earlier (SAMHSA, 1999). The motivational, like the strengths approach, meets the client where he or she is at that point in time. The harm reduction practitioner as- sesses the level of the client’s motivation for change, and instead of engaging in a tug of war with the client, “rolls with resistance.” MI tech- niques are geared to help people find their own path to change. The thera- pist provides feedback through additive paraphrasing, a technique that involves selectively disseminating to the client what he or she seems to be saying about the need to reduce or eliminate self-destructive behav- iors (van Wormer and Davis, 2003). Table 1 presents the critical components of MI in a nutshell. These six elements of current motivational approaches have been identified and presented in brief clinical trials (SAMHSA, 1999). They are sum- marized by the acronym FRAMES. WHAT IS THE SCIENTIFIC EVIDENCE FOR THIS APPROACH? In the Substance Abuse Field Most studies to date have been conducted in the treatment of substance abuse disorders (Miller & Rollnick, 2002). A review of the evidence-based 24 JOURNAL OF TEACHING IN SOCIAL WORK literature reveals that motivational techniques are particularly useful as a prelude to other services such as in employee assistance programs where treatment encounters are brief. The most widely cited and ex- haustive study in the literature pertaining to MI is the eight-year-long comparison study directed by the National Institute on Alcohol Abuse and Alcoholism, Project MATCH (1997). Project MATCH involved al- most 2,000 patients in the largest trial of psychotherapies ever under- taken. The goal of this $28 million project was not to measure treatment effectiveness, but, rather, to study which types of treatments worked for which types of people. The three treatment designs chosen for this extensive study were based on the principles of the three most popular treatment designs– conventional Twelve-Step-based treatment, cognitive strategies, and motivational enhancement therapy. All therapy provided was individu- ally rather than group based for more rigorous control of the process. In- dividuals were assigned randomly to the three varieties of treatment. Among the treated subjects, less successful outcomes were associ- ated with male gender, psychiatric problems, and peer group support for drinking. Because there was no control group deprived of treatment, generalizations concerning the efficacy of treatment cannot be made, a fact that has brought this massive project in for considerable criticism (Bower, 1997). What this extensive and long-term study does show, however, is that all three individually delivered treatment approaches are Katherine van Wormer 25 TABLE 1. FRAMES: Critical Elements of Effective Motivational Intervention •Feedback regarding personal risk or impairment is given to the client following assess – ment of substance abuse patterns (or other risk-taking behaviors) and associated problems. • Responsibility for change is placed squarely and explicitly on the client (with respect for the client’s right to make choices for himself or herself). • Advice about changing–reducing or stopping–harmful behavior is clearly given to the client by the clinician in a nonjudgmental manner. • Menus of self-directed change options and treatment alternatives are offered to the client. • Empathic counseling–showing warmth, respect, and understanding–emphasized. • Self-efficacy or optimistic empowerment is engendered in the client to encourage change. Note : This table is based on information in SAMHSA (1999) TIP 35 published by the U.S. Department of Health and Human Services and inspired by the work of Miller and Rollnick. relatively comparable in their results, that treatment that is not abstinence based (motivational enhancement) is as helpful in getting clients to re – duce their alcohol consumption as the more intensive treatment designs. That abstinence could be a long-term but not immediate outcome of this treatment protocol was another significant finding of this mass experiment. The format was this: Treatments were provided over 8- and 9-week periods, with motivational therapy being offered only four times and the other two designs offering 12 sessions. All of the participants showed significant and sustained improvements in the increased percentage of days they remained abstinent and the decreased number of drinks per drinking day. However, treatment researchers noted that outpatients who received the Twelve-Step facilitation program were more likely to remain completely abstinent in the year following treatment than were outpatients who received the other treatments. Individuals high on reli- giosity and those who indicated they were seeking meaning in life gen- erally did better with the Twelve-Step, disease model focus, while clients with high levels of psychopathology did not. Clients low in motivation did best ultimately with the design geared for their level of motivation. An interesting outcome of this study is that insurance companies have come to endorse MI treatments, undoubtedly due to its brevity and therefore cost effectiveness (van Wormer & Davis, 2003). Their en- dorsement, in turn, has bolstered their client-centered approach for use in substance abuse counseling. I believe it has an applicability that goes far beyond the substance abuse field. If the techniques work well with alcoholics reluctant as they are to give up the use of mood altering sub- stances, how much more amenable such techniques might be in other treatment areas–in standard health care and mental health counseling, for example. Empirical Research in Other Areas While the literature is still emerging in areas apart from substance abuse counseling, available evidence suggests that motivational strate- gies hold great promise for promoting healthy behavior change. In their review of the health care literature, Resnicow, DiIorio et al. (2002) found that for nonaddictive behavior, less time may be needed to re- solve client ambivalence; and compliance measures are less tangible for some health-promoting behaviors than, for example, cigarette use. Brief adaptations of MI are often used for such situations of limited contact. 26 JOURNAL OF TEACHING IN SOCIAL WORK One difficulty in the medical field concerns the training of personnel used to giving orders to adopt a new style of relating to patients. Besides, physicians and nurses are often too busy to put the adequate time into training and role plays. Experiments using counselors, psychologists, and social workers, however, have achieved significantly better results compared with standard intervention groups in obtaining diet changes in overweight diabetics, overweight children, and patients at risk of cor – onary heart disease (Resnicow, DiIorno et al., 2002) Promising results have been found in work with schizophrenic patients as well. Participants who attended several motivational sessions showed much improvement in attitudes toward drug treatment and greater insight into their illnessthan did participants in a support counseling group (Kemp, Kirov et al., 1998). More rigorous studies are needed, however, before we can definitely state that MI outshines other means of ensuring medical patient compli- ance. Mueser et al. (2003) conducted a review of systematically con- trolled research into treatments for dually diagnosed patients. What these researchers found was that the programs with the best results were inte- grated (to treat both the substance abuse and the mental disorder), were long term, and were motivation-based. An even greater challenge in terms of employee training and non- compliant participants is found in the criminal justice field. Ginsburg, Mann et al. (2002) pursue the investigation of motivational work in this highly authoritarian milieu. Referring to Project MATCH, these authors indicate that given the success of motivational strategies with alcoholics many of whom were offenders, further research would likely show that MI has application with offender populations in general. Further credence is provided to this supposition in the finding that MI strategies achieved a high level of success in working with clients who initially were angry. Ginsburg, Mann et al. (2002) cite several preliminary studiesshowing that harsh confrontational techniques have less effect in promoting change in offenders than do motivational interventions. Their recommendation for MI with sexual offenders is based on case studies from the United Kingdom which documented that sexual offenders responded well to this approach. It seems self evident that any strategy designed to foster inter- nally motivated behavior change should have more success in offender rehabilitation as opposed to more externally imposedcontrols. A key ad- vantage of MI is its ability to tailor particular intervention strategies to the individual client’s position on the stages-of-change continuum. Let us consider these strategies in some detail. Katherine van Wormer 27 THE STAGES-OF-CHANGE MODEL People are ultimately capable of making an informed choice in their own best interest. The choices they make depend on their readiness to change, i.e., what stage of change they are in at a certain point in time (van Wormer & Davis, 2003). The stages-of-change model, sometimes referred to as the Transtheoretical Model because it relies on several theories of social psychology, was first proposed by Prochaska and DiClemente (1986) for use in helping smokers break their nicotine habit. The model has since been applied and adopted in many addiction treat – ment and other helping settings around the world. DiClemente and Velasquez (2002) describe the series-of-change model as follows: In this model change is viewed as a progression from an initial precontemplation stage,where the person is not currently consid- ering change; tocontemplation,where the individual undertakes a serious evaluation of considerations for or against change; and then topreparation,where planning and commitment are secured. (p. 201) Once the initial stage tasks are accomplished, as DiClemente and Velasquez (2002) further inform us, clients can be expected to takeac- tiontoward change; such action steps, in turn, lead to the final and fifth stage of change,maintenance,in which the person works to maintain long-term change. If the individual falters, however, a sixth stage– relapse or recurrenceof the behavior–may occur. Such backtracking is considered a normal part of the behavior change process. The stages-of-change model is a natural fit with MI and harm reduc- tion practices because of the primary focus on client choice and the em- phasis on helping people progress through the stages at their own pace. Instead of a dualistic, one-size-fits-all framework where there is either complete recovery or total failure, this approach offers the possibility of small steps punctuated by expected set-backs on the road to a resolution of one’s problems. The starting point for the therapist is to determine where the client is, at what level of change. As Boyle (2000) indicates, it is not unusual for involuntary clients to enter treatment at theprecontemplativestage. For the purposes of illustration, let us assume the client is a hard-drinking teenager brought to treatment through a court order. Typical teenage comments at each level of the stages of progression are contained in Table 2. 28 JOURNAL OF TEACHING IN SOCIAL WORK During the initial precontemplation stage of work with the typical teen drug user, the goals for the therapist are to establish rapport, to ask rather than to tell, and to build trust. Eliciting the teen’s definition of the situation, the counselor can reinforce discrepancies between the client’s and others’ perceptions of the problem. During thecontemplationstage, while helping to tip the decision toward reduced drug/alcohol use, the counselor emphasizes the client’s freedom of choice. “No one can make this decision for you” is a typical way to phrase this sentiment. Informa- tion is presented in a neutral, “take-it-or-leave-it” manner. Typical ques- tions are, “What do you get out of drinking?” “What is the down side?” And to elicit strengths, “What makes your family member believe in your ability to do this?” At thepreparationfor change andactionstages questions like, “What do you think will work for you?” help guide the youth forward without pushing him or her too far too fast. Patricia Dunn (2000) finds that the stages of change model is appro- priate for social work because it is compatible with the mission and con- cepts of the profession, is an integrative model, and is grounded in empirical research. Through building a close therapeutic relationship, the counselor can help the client develop a commitment to change. The way motivational theory goes as this: If the therapist can get the client to do something,anything, to get better, this client will have a chance at suc- cess. This is a basic principle of social psychology. Examples of tasks that William Miller (1998) pinpoints as predictors of recovery are going to AA meetings, coming to sessions, completing homework assignments and taking medication (even if a placebo pill). The question, according to Miller, then becomes, “How can I help my clients do something totake Katherine van Wormer 29 TABLE 2. An Ambivalent Teen Progresses Through the Stages Stage of Change Adolescent Comments Precontemplation My parents can’t tell me what to do; I still use, so what if I get high now and then? Contemplation I’m on top of the world when I’m high, but then when I come down, life is a drag. It was better before I got started on these things. Preparation I’m feeling good about setting a date to quit, but who knows? Action Staying clean may be healthy, but it sure makes for a dull life. Maybe I’ll check out one of these groups. Maintenance It’s been a few months; I’m not there yet but I’m hanging out with some new friends. action on their own behalf?” A related principle of social psychology is that in defending a position aloud, as in a debate, we become commit – ted to it. One would predict, from motivational enhancement perspec – tive, that if the therapist elicits defensive statements in the client, the client will become more committed to the status quo and less willing to change. For this reason, explains Miller, confrontational approaches have a poor track record. Research has shown that people are more likely to grow and change in a positive direction on their own than if they get caught up in a battle of wills. In their seven-part professional training videotape series, Miller and Rollnick (1998) provide guidance in the art and science of motivational enhancement. In this series the don’ts are as revealing as the do’s. Ac- cording to this therapy team, the don’ts, or traps for therapists to avoid, are as follows: • A premature focus, such as on one’s addictive behavior • The confrontational/denial round between therapist and client • The labeling trap–forcing the individual to accept a label such as alcoholic or addict • The blaming trap, a fallacy that is especially pronounced in cou- ples counseling To learn more about the specifics of this technique, students can visit the CSAT (Center for Substance Abuse Treatment) Website at www.csat. samhsa.gov. TIP 35, “Enhancing Motivation for Change” can be ordered from this site. Also consult www.motivationalinterview.org for further information. GOODNESS OF FIT WITH THE SOCIAL WORK CURRICULA Clearly, students in substance abuse courses must learn the skills of motivational interviewing, as this is the method increasingly endorsed by insurance companies and substance abuse treatment agencies (van Wormer & Davis, 2003). But social workers in other areas, whether child welfare (parental substance abuse is often a factor), corrections (where the need for decision making in the direction of law abiding behavior is paramount), or mental health agencies (where medical compliance may be a key to good health), will also find a grounding in 30 JOURNAL OF TEACHING IN SOCIAL WORK motivational techniques highly useful. The relevance of motivational training to four other areas of social work education, the core areas of social work, namely, (1) practice, (2) human behavior, (3) research, and (4) policy, are described as follows. Practice Social work practice courses tend to focus on treatment after the fact of personal crisis often involving self destructive behavior rather than on prevention; such courses also tend to focus on individual rather than public health. Yet there is a well established body of literature on effec – tive prevention of behaviors such as teen pregnancy, and reduction of disease risk that should be included in advanced practice courses fo- cused on working with families, children, and adolescents (Williams, Rounds, & Copeland, 2002). Skills development in risk-reducing behav- ior along the lines of learning how to elicit motivation inducing state- ments in clients is invaluable in this regard. Human Behavior in the Social Environment (HBSE) Why people do the things they do and which life events or interven- tions can be turning points in people’s lives are themes of undergraduate and graduate courses in human behavior. An in-depth study of motiva- tion to change is an important aspect of the psychology of human behav- ior, one that is often overlooked in HBSE courses. Yet the connection to human development issues that traditionally comprise the knowledge base of the HBSE curriculum of human motivation is obvious. Research Motivational theory has been an outgrowth of social psychology re- search into decision making. Students, in their critical analysis of evi- dence-based treatment interventions can benefit by exploring the burgeoning research on strategies to elicit motivation. Advanced re- search students can be made aware of the wealth of grant funded oppor- tunities in experimental research in this area. This fact of this demand can be borne out by an Internet search with the substance abuse search engine,www.jointogether.org. This resource provides announcements of funded research opportunities related to substance abuse treatment interventions. Katherine van Wormer 31 Policy How to provide client-based treatment against the backdrop of an under-funded and punitive social welfare system–students of policy will have to tackle that problem. Policy courses should include content on the need for government policies conducive to prevention of disease and to a treatment climate conducive to motivational strategies. Students can be referred towww.statepolicy.org, the Influencing Social Policy Web site, and the Harm Reduction Coalition at . CAUTIONARY NOTE There is some risk that the authorities (government officials, insur- ance companies) will co-opt motivational interviewing techniques and that, in so doing, they will miss the spirit of this client-centered effort. Accordingly, the effort will not be client-centered at all but, in fact, might be construed as a ruse to elicit information from a trusting client. Consider Iowa as a case in point. My observations are drawn from in- formal interviews with authorities at the Iowa Board of Substance Abuse Certification and through conversations with individual counselors. The board of certification requires proficiency in motivational techniques; MI trainings are offered throughout the state for all counselors. The impetus for this apparent paradigm shift, in all probability is related to insurance company reimbursement incentives. Following Project MATCH results that show motivational counseling achieves effectiveness in fewer sessions than does the Twelve-Step or cognitive approach, third party payers logi- cally promote MI strategies as more cost effective. The paradigm shift that I refer to earlier is more apparent than real given the authoritarian structure within much counseling activity that takes place. Treatment compliance is apt to be mandated, often under the threat of imprisonment or loss of driving privileges. Harm reduction philosophy, the guiding model for substance abuse treatment in many European countries, is congruent with a voluntary system in which the clients come and go as they choose and total abstinence is not required. Most treatment in the Untied States, in contrast, is geared toward the court-ordered client. So MI-trained counselors for all their high-powered listening skills and experience in eliciting insightful responses in the cli- ent, are often in the position of wearing two hats, one as a counselor meeting the client where the client is, the other as an employee of the state, county or even correctional establishment. As one counselor put 32 JOURNAL OF TEACHING IN SOCIAL WORK it, “The client opens up and tells you everything and you’re having a great session. The last five minutes you suddenly change your tactics and say, ‘You have a serious problem and will be required to attend so many treatment sessions and you must be drug free the whole time’ and the client gets furious and feels deceived and says something like ‘but you said I didn’t seem to have much of a problem’” (personal interview of April 8, 2004). DiClemente and Velasquez (2002) address this issue indirectly, they caution that to elicit a list of the “cons” in using an addictive substance and then later to use these statements as ammunition against the client defeats the purpose of the exercise (the listing the pros and cons of drug use). They advise that the clinician should trust clients to reach their own conclusions. Until the structure, at least in the substance abuse and correctional areas, is less authoritarian and punitive, motivational strat- egies can only go so far. Such an approach is ideal, however, at mental health centers and private counseling clinics where clients come more or less of their own accord. I have used such strategies with adults in treatment for mental disorders and with teenagers brought into treatment by their parents to good effect. CONCLUSION Social workers in whatever field of practice are change agents, or hope to be. In their individual, group, and family work, the aim is to help people help themselves. Students of social work, therefore, need training in the most psychologically effective methods known to modern science. Motivational enhancement strategies have been shown to be effective in curbing risk taking behaviors, especially related to health and mental health. Motivational techniques are highly effective in helping clients move from a precontemplative stage to an action stage of behavior change. Social work educators can help their students shape appropriate interven- tions to reflect client stages of motivation. HBSE instructors can focus on the human behavior components in MI theory and learn how and why MI works better than harsh confrontation. Courses on health and mental health can focus on the prevention attributes of motivational concepts. Finally, policy courses can consider the structural impediments to insti- tuting client centered programming. In substance abuse and offender situations, however, the American social structure is not always conducive to a treatment regimen centered on the principles of stages-of-change which proceed at the client’s, not the treatment center’s, pace. Katherine van Wormer 33 MI has a tremendous potential in areas in which clients are subjecting themselves or are being subjected by others to harm. I am thinking of the victims of domestic violence or family members of persons with ad – dictions problems or mental illness in need of help to prevent the situa – tion from growing desperate. Because of its versatility, MI techniques can be taught to practitioners at various agencies. This commonality of treatment approach should help bridge the gap between agencies (for example, women’s shelter and substance abuse treatment centers) whose philosophy in the past has clashed due to professional bias and incon – gruities in focus. A main advantage of such a common approach is that services for treatment of clients with dual and multiple diagnoses could be readily integrated to meet client needs and to provide more consis- tency in approach. REFERENCES Bower, B. (1997). Alcoholics anonymous.Science News, 151, 62-63. Boyle, C. (2000). Engagement: An ongoing process. In A. Abbott (Ed.),Alcohol, tobacco, and other drugs(pp. 144-158). Washington, DC: NASW Press. Denning, P. (2000).Practicing harm reduction psychotherapy: An alternative ap- proach to addictions. New York, NY: Guilford Press. DiClemente, C. & Velasquez, M. (2002). Motivational interviewing and the stages of change. In W. R. Miller & S. Rollnick (Eds.),Motivational interviewing: Preparing people for change(2nd ed., pp. 201-216). New York, NY: Guilford. Dunn, P. (2000). Dynamics of drug use and abuse. In A. Abbott (Ed.),Alcohol, tobacco and other drugs: Challenging myths, assessing theories, individualizing interven- tions(pp. 74-110). 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(1998).The strengths model: Case management with people suffering from severe and persistent mental illness. New York, NY: Oxford University Press. Resnicow, K., DiIorio, C., Soet, J., Borrelli, B., Ernst, D., Hecht, J., & Thevos, A.(2002). In W. Miller & S. Rollnick,Motivational interviewing: Preparing people for change(2nd ed., pp. 201-216). New York, NY: Guilford. Saleebey, D. (2002). Introduction: Power to the people. In D. Saleebey (Ed.),The strengths perspective in social work practice(3rd ed., pp. 1-22). Boston, MA: Allyn & Bacon. Substance Abuse and Mental Health Services Administration (SAMHSA) (1999). Enhancing motivation for change in substance abuse treatment. TIP 35. Rockville, MD: SAMHSA. van Wormer, K. & Davis, D.R. (2003).Addiction treatment: A strengths perspective. Belmont, CA: Wadsworth. doi:10.1300/J067v27n01_02 Katherine van Wormer 35
Change Process
The School Brawler This intervention took place in a school setting, where the social worker saw a 12-year-old African-American girl named Bettina, who had been in trouble for frequent fighting. Following a few minutes of introduction, Robyn, a 26-year-old Caucasian female, began by setting a brief agenda: “Bettina, you’ve been sent to me to talk about some problems at school and what we can do about those, but we can also talk about whatever else you think is important.” In this way, Robyn directed the focus of the meeting, but allowed for flexibility so that any or all of the client’s concerns could be given attention. Still, Bettina chose to focus on the presenting problem. The social worker listened with empathy as she tried to elicit statements about change from the client. She asked Bettina, “What are some of the good things about fighting?” and “What are some of the not-so-good things about fighting?” Like many clients, Bettina was surprised at the former line of question- ing. Robyn explained, “There must be some good things about it, otherwise you wouldn’t keep doing it, right?” As Bettina responded, the social worker probed for more information and selectively reinforced the client’s statements about change. When reflecting on why she liked to fight, Bettina said that it made her feel proud when she won. It also ensured that her peers “respected” her. On the other hand, Bettina said she didn’t want to get expelled from school or end up in juvenile hall. She was also afraid of hurting people. For instance, she found herself pounding another girl’s head against the sidewalk during one fight, and she didn’t want to do that kind of thing. Rather than just allowing Bettina to list these reasons for not fighting, Robyn explored with her the disadvantages of the status quo. For in- stance, the social worker asked, “What worries you about getting expelled for fighting? How will getting expelled for fighting stop you from doing what you want in life?” Thus the social worker helped the client talk herself into changing rather than using direct persuasion. The social worker avoided challenging the client’s statements because direct confrontation was likely to escalate resistance rather than reduce it. Any resistance to change was sidestepped. For instance, when Bettina said, “If I don’t fight, I’ll get disrespected,” the social worker used the technique of amplified reflection: “So the only way to get people’s respect is to fight them.” Amplified reflection often results in verbal backpedaling from the client, who attempts to soften the extreme posi- tion reflected by the social worker. In this case, Bettina said, “No, sometimes I just give them a look. I can give some pretty mean looks.” As part of her motivational interviewing, Robyn picked up on what the cli- ent held as important in her life. She then worked to enlarge the discrepancy between the client’s values and her present problem behavior. Bettina valued her friendships at the school, but her fighting was endangering those relation- ships: “So on one hand, those friends are important to you, and on the other, if you get expelled for fighting and get transferred to another school, you won’t be able to see your friends like you do now.” As the conversation continued, the social worker focused on instilling in Bettina some optimism about change. For instance, when Robyn asked the question, “What makes you think that if you decided to make a change, you could do it?” Bettina said, “I can do it if I set my mind to it. I only wanted to cut my fighting down a little bit before. But now I want it to stop.” Robyn asked, “What personal strengths do you have that will help you succeed?” The client answered, “I can talk. I know how to talk to people so they don’t mess with me. I just lay them straight. No need to fight most of the time.” Robyn further inquired about who could help Bettina make these changes. She identi- fied her friends as a support system: “I can say to them, ‘you-all, talk me down, because I can’t fight no more. I don’t want to get kicked out of school.’ So when I’m in an argument, they’d probably say something like, ‘forget her— she ain’t worth it.’ And they’d be right—she ain’t.” The social worker assessed the client’s commitment to change, as well as her confidence that she could make changes. To begin, Robyn used the commit- ment ruler technique: “If there was a scale to measure your commitment, and it went from 0 to 10, with 10 being totally committed—nothing could make you fight—where would you say you are right now?” Bettina identified herself at a “7,” and Robyn asked her to account for this value. Bettina said, “One more fight, and I’m kicked out of school. They already told me that. They might mean it this time.” The social worker then asked Bettina to rate herself on a similar ruler in- volving her confidence that she could change. Bettina gave herself a “5” ranking, and said, “I already changed some. Like last year I got in trouble every day, but this year I don’t get in trouble very often. I try to stay away from people I got a problem with. Before, I wouldn’t think about it, and I would just fight people and not think about what would happen. But now I think about it.” Because Bettina’s confidence that she could change was lower than her commitment, Robyn turned to a technique that would enhance the client’s self-efficacy, asking evocative questions: “How might you go about continuing to make change? What would be a good first step?” Bettina answered that she would continue to avoid people who bother her. She would also talk to her friends about helping her “calm down.” When asked about possible obstacles, Bettina admitted that it could be diffi- cult if someone “got up in her face.” The social worker and client began brain- storming about how to handle this obstacle. With some prompting and suggestions, Bettina produced three options: making threats but not necessarily following through, staying in public settings so that other people could intervene, and telling the instigator, over and over again if need be, “You’re not worth it.” In motivational interviewing, when the social worker offers information and advice, it is phrased tentatively (“If it’s okay, I’m going to make a suggestion. I don’t know if it will work for you or not. It’s worked for others who have struggled with the same things you have.”). The social worker avoids struggling with the client about what she must do. Instead, the social worker strategically applies techniques so that the client’s motivation to change is bolstered. In this way, during the course of a single session, Bettina decided that she was ready to commit to a change plan. She met with Robyn for several more weeks, report- ing on her progress in staying out of fights and getting feedback that helped to maintain her positive direction.
Change Process
transtheoretical stage of change Another major influence on motivational interviewing is the trans- theoretical stages of change (TSOC) model, developed to recognize and address the reluctance of many people with substance use disorders to change their behaviors. TSOC offers an alternative to approaches that view clients as resistant, in denial, or uncooperative if they express a lack of readiness or willingness to change. It views motivation as a state of readiness to change and proposes that all people follow a predictable course when changing behavior. The following six stages of change have been formulated in the TSOC: Precontemplation—The person does not believe that he or she has a prob- lem and is unwilling to change, even though others suggest there may be a problem. Contemplation—The person is considering changing a behavior, seeing that there are significant benefits to be gained by (for example) stopping alcohol use, even as he or she continues to drink. Preparation—The person is poised to change the problematic behavior within the next month, and works on a strategy for doing so. Action—The person implements a change in behavior (for example, going to rehab). Maintenance—Sustained change persists for six months. Relapse—The person resumes the problem behavior. The TSOC model may seem simple, but as a guide to approaching inter- vention, it has advanced the process of treating substance abusers remarkably. The model has also been tested with other kinds of presenting problems such as dietary change (Armitage, 2006), male battering behavior (Scott & Wolfe, 2003), and smoking cessation and exercise adoption (Rosen, 2009), and has been found to be a largely (but not completely) valid predictor of client change. Motivational interviewing focuses mainly on clients in the first three stages of change, while motivational enhancement therapies guide a client through the fourth and fifth stages. Collaboration, rather than confrontation, is a hallmark of motivational inter- viewing and enhancement. Indeed, within this perspective, confrontation is “sidestep” denial, and instead emphasize listening reflectively to clients’ concerns and supporting change talk. This is defined as talk that emphasizes the: Disadvantages of the status quo Advantages of change Optimism about change Intention to change Motivational interviewing also contrasts with the principles of Alcoholics Anonymous (AA), a dominant treatment paradigm demanding that people label themselves as alcoholic and admit their powerlessness over alcohol. MI down- plays the use of labels, stressing more of a non-hierarchical collaboration between the client and practitioner, as well as the development of self-efficacy so the client can develop confidence for changing

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